Disease Management
We offer a disease management system
Designed to help individuals prevent the progression of disease and to preserve independence. Disease management services are overseen by physicians and a team consisting of a nurse practitioner, registered nurse, case manager, and dietician.
How the Process works:
1. Contact Southeast Community Health Systems
2. Screening, Assessment, and Planning
i. The Care Team assesses the patient's condition and identifies barriers to managing the disease or accessing health care.
ii. Services include assessment of and guidance with the following:
- Monitoring, recognition, and treatment of symptoms
- Medication management
- Nutrition habits
- Memory disorders or depression
- Physical Condition
- Transportation to medical appointments
- Paying for prescriptions or other financial barriers to health and well-being
- Obtaining affordable insurance
- Coordination of care from hospital to home or community setting
- Referrals to other community resources
3. Ongoing follow-up and Support
The Disease Management Care Team and the patient develop goals within the plan of care, as prescribed by the patient's health care provider. In addition, the patient has access to educational programs, physical activities, and support groups.